Provider Demographics
NPI:1356131833
Name:SELFAISON, RYAN IKAIKA
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:IKAIKA
Last Name:SELFAISON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:854 N 560 W
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-3528
Mailing Address - Country:US
Mailing Address - Phone:808-220-5329
Mailing Address - Fax:
Practice Address - Street 1:865 N 900 W
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-7701
Practice Address - Country:US
Practice Address - Phone:385-236-5365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10261211-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist